Best Practices in the ICU Still Stand
University of Michigan researchers who compared outcomes between two studies conducted among patients with lung failure who died from COVID-19 and patients with lung failure who died prior to the pandemic have concluded that while differences exist in the two groups, best practices in place for ICU care still apply to COVID-19 patients.
The COVID-19 study was published in a recent edition of the Annals of the American Thoracic Society and looked at 82 people who died of COVID-19 in the spring and early summer of last year. An examination of the cause of death found 56% primarily died due to lung failure. The previous study, published by Critical Care this past summer, examined data on more than 380 people with similar lung failure who died prior to the pandemic. Only 22% of those people died primarily because of lung damage or dysfunction.
In both groups of patients, sepsis was the primary cause of death in 26%.
“These findings underscore the importance of trying to deliver evidence-based interventions for respiratory failure in COVID-19 patients as the pandemic continues, especially as professionals who don’t normally treat this condition or work in an ICU are pulled into service,” said Scott Ketcham, MD, who led both studies.
He defines those interventions as prone positioning, a good working knowledge of mechanical ventilation, appropriate selection of patients to receive heated high flow oxygen, and early recognition and treatment of infection. “In other words,” Dr. Ketcham said, “following guidelines developed before by those who specialize in treating respiratory failure like acute respiratory distress syndrome and sepsis.”
Inhaled Medication Shows Promise for Patients with PH-ILD
In a study conducted among 326 adult patients with pulmonary hypertension associated with interstitial lung disease (PH-ILD) who were randomized to a treatment or placebo group, researchers have found that treatment with the inhaled medication Tyvaso improved exercise capacity, decreased risk of clinical worsening, improved forced vital capacity, and reduced exacerbation of underlying lung disease.
The improvement in exercise capacity, as measured by the six minute walk test, was seen across all subgroups in the study, including those related to etiology and severity of the disease, age, gender, baseline hemodynamics, and dose. The treatment was well tolerated as well, with only mild to moderate treatment-related adverse events.
“Patients with both interstitial lung disease and pulmonary hypertension are more likely to have a worse course of disease and worse survival rate than patients with interstitial lung disease alone,” said Steven D. Nathan, MD, one of the study investigators from Inova Fairfax Hospital and Virginia Commonwealth University-Inova Campus, in Fairfax, VA. “Having an approved inhaled treatment to offer my patients with PH-ILD would be transformational for the medical community and, importantly, for patients living with this disease.”
The study was published by The New England Journal of Medicine in January.
Adding Baricitinib to Remdesivir Improves Outcomes
New research in The New England Journal of Medicine suggests combining remdesivir with the drug baricitinib can improve outcomes for patients who are hospitalized with COVID-19. The Adaptive COVID-19 Treatment Trial (ACCT-2) involved hospitalized patients who were being treated with high oxygen by nasal cannula or were receiving breathing assistance via a mask. Time to recovery for those treated with the combination therapy was 10 days. Those who received remdesivir plus placebo had a time to recovery of 18 days.
The 28-day death rate was also lower in the combination therapy group, 5.1% vs. 7.8%.
Approved for the treatment of patients with active rheumatoid arthritis, the anti-inflammatory baricitinib received emergency use authorization from the FDA last November for use in combination with remdesivir for the treatment of suspected or laboratory-confirmed COVID-19 in hospitalized adults and pediatric patients age two or older requiring supplemental oxygen, invasive mechanical ventilation, or extracorporeal membrane oxygenation.
“We are making progress in the treatment of COVID-19,” said principal investigator Thomas Patterson, MD, professor, and chief of infectious diseases at UT Health San Antonio, one of the study sites. “Remdesivir markedly improved recovery of critically ill patients in the first ACTT study, and baricitinib further helped patients in this second study.”
The ACTT-2 was supported by the National Institute of Allergy and Infectious Diseases and conducted at 100 sites around the world.
DNA Tests Predict Worse Outcomes from COVID-19
Two recent studies find DNA tests can help determine which COVID-19 patients will go on to suffer from secondary infections and more severe disease.
British investigators publishing in Critical Care developed a test that uses multiple polymerase chain reaction (PCR) to detect the DNA of pneumonia bacteria in about four hours. The test runs multiple PCR reactions in parallel, enabling it to simultaneously identify 52 different pathogens known to infect the lungs of patients receiving care in the ICU. The test can also identify antibiotic resistance of those pathogens.
“We found that although patients with COVID-19 were more likely to develop secondary pneumonia, the bacteria that caused these infections were similar to those in ICU patients without COVID-19,” said lead author Mailis Maes, from Cambridge University. “This means that standard antibiotic protocols can be applied to COVID-19 patients.”
In a study that appeared in JCI Insight, researchers from Washington University School of Medicine in St. Louis found a rapid blood test measuring mitochondrial DNA levels can predict which patients with COVID-19 are at highest risk of severe complications or death.
“Viruses can cause a type of tissue damage called necrosis that is a violent, inflammatory response to the infection,” said study author Andrew E. Gelman, PhD. “In COVID-19 patients, there has been anecdotal evidence of this type of cell and tissue damage in the lung, heart, and kidney. We think it’s possible that measures of mitochondrial DNA in the blood may be an early sign of this type of cell death in vital organs.”
Dr. Gelman and his colleagues used the test to evaluate 97 patients with the disease. On average, mitochondrial DNA levels were about tenfold higher in those who went on to develop severe lung dysfunction or die. Patients with elevated levels were nearly six times more likely to require intubation, three times more likely to be admitted to the ICU, and almost twice as likely to die when compared to patients with lower levels.
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